It’s just banter. That’s how people justify denigration of one medical specialty by another, and that’s what the majority of medical students believe; all specialties go through it and all specialties do it; it’s character building; it’s just a bit of fun.1

But one consequence is that medical students are being put off entering certain specialties because of the stigma attached to them.1

This is dangerous. It has been shown that this adversely affects two specialties more than others: general practice and psychiatry.1 And if we don’t have enough GPs or psychiatrists, the NHS will certainly fail, and it will be our patients who suffer most.

All in the name of ‘banter’.

AN OVERVIEW OF THE ISSUE

Humans are complex, both in body and mind, so we need different medical specialties. We need people to look after our hearts; specialise in our skin; physically fix us, with tools, when we are broken. But as we strive for parity of esteem between physical and mental health, we need people to understand our minds, and vitally we need people to oversee the ‘whole person’, dealing with health conditions before they become too serious, and appropriately navigating patients through the NHS.

It has been shown that denigration leads to medical students rejecting certain specialties.1 With general practice and psychiatry repeatedly shown to suffer most denigration, it’s safe to assume that these are the specialties most negatively impacted.

This correlates with figures from Health Education England (HEE). In 2015, 604 GP and 91 psychiatry placements were left unfilled: the highest of any medical specialties.2

In general practice we are expecting improvements this year, partly due to the recruitment efforts by the Royal College of General Practitioners (RCGP) and HEE — and the Royal College of Psychiatrists (RCPsych) is following suit; but that isn’t the point. If ingrained negative attitudes towards general practice and psychiatry exist in medical schools, which we know they do, if these attitudes persuade potential GPs and psychiatrists to choose alternative specialties for fear of being stigmatised, which we know they do, and if this leads to a shortfall in the number of GPs and psychiatrists needed to deliver the care our patients need, which we know it does, then we need to tackle this issue, fast.

The hierarchy that has been created puts physical health over mental health, hospital care over community care, specialism over generalism, and ‘medical’ specialties over ‘non-medical’ ones.3,4 This must be replaced by respect and understanding throughout medicine that all specialties are important, that all specialties have their own set of skills and values, and that the NHS will only function properly when we have sufficient numbers of doctors practising all specialties.

THE GP SITUATION

NHS England Chief Executive Simon Stevens has said, ‘there is arguably no more important job in modern Britain than that of the family doctor’, and he’s right.5

GPs don’t specialise in one part of the body (or mind), but are expert medical generalists, and in being so we and our teams conduct 90% of NHS patient contacts.6 With our growing and ageing population, and patients increasingly presenting with multiple, long-term conditions, general practice is more important than ever in providing cost-effective care and keeping patients out of hospitals.7

We can’t do this without enough GPs.

HEE now has a standing target to encourage 50% of medical students into general practice. Furthermore, NHS England’s GP Forward View pledges 5000 more GPs by 2020/2021, but GPs don’t grow on trees and fighting against a toxic force from within medicine is an unnecessary barrier to achieving this goal.

Research spanning the last 20 years shows that the existing hierarchy perpetuates the view that hospital-based specialties offer more excitement, clinical challenge, and prestige than general practice.3,4 It is often seen as a ‘fail-safe’ or ‘back-up’ option; not the message we want to convey to 50% of the future workforce.

The NHS recognises and understands the importance of general practice. Our patients understand it: in the last GP Patient Survey, 92% had trust and confidence in the last GP they saw.8 So fellow doctors who impart their attitudes to medical students need to understand it too.

THE PSYCHIATRIST SITUATION

Psychiatry also suffers its fair share of denigration. It was recently found second only to general practice regarding denigrating comments directed towards the specialty.1

Although there are certainly recruitment implications — with increasing levels of multimorbidities in patients being both physical and mental, any shortage in the number of psychiatrists we have is a problem — the more concerning ramification here is the sinister form that banter towards psychiatry takes.

It encourages a disturbing association between psychiatrists and their patients, with comments such as ‘psychiatrists are crazy themselves’.1 We also hear regular reports of throwaway comments in everyday practice alluding to mental health patients being hypochondriacs or psychiatrists as, for example, ‘pest controllers’.

Deriding psychiatrists — and our patients — in such a way stimulates stigma in society and in doing so risks discouraging patients with mental health conditions from seeking help, for mental and physical health issues.

This is entirely incongruous with the current drive for parity of esteem between physical and mental health, a governmental priority.

Such besmirching and stigmatising banter ultimately disrespects and threatens the health of our patients. A learning environment that allows this to exist does not foster any such parity and if we don’t have parity of esteem between physical and mental health within medicine, then how can we expect it to exist outside?

It’s not that psychiatrists can’t take and make jokes. We can — think of the films of Woody Allen — but this joke is not on psychiatry, or psychiatrists. It is on our patients with mental health conditions, and that is unacceptable. And given that the majority of mental health patients will not be directly treated by psychiatrists, but elsewhere in the NHS, this becomes a joke on everyone.

THE CASE FOR ‘BANNING THE BASH’

The systematic denigration we are seeing in medical schools is founded on misperceptions that maintain a negative impression of both general practice and psychiatry, and a lack of respect for the importance of these specialties. It is exacerbating a shortage of GPs and psychiatrists in the NHS, and directly contravenes efforts to achieve parity of esteem between physical and mental health, causing a negative impact on patient care.

This isn’t about censorship. There is nothing worse than creating a learning environment where people are afraid to speak their mind.

It isn’t about the prohibition of banter within medical schools. Such a paternalistic and sanctimonious approach would simply push denigration underground, where it can be just as harmful in the form of knowing looks and in-jokes.

It is about fostering respect between specialties and an understanding that the NHS is predicated on having sufficient numbers of all medical specialties, so that we can keep patients safe and well. It is about breaking down any hierarchy that suggests one medical specialty is worth any less than another.

It is about insisting that all of our patients, with physical health problems, mental health problems, or both, are treated with respect and dignity. Currently, medicine is lagging behind wider society in achieving parity of esteem between physical and mental health.

Some will say that we are blowing the issue out of proportion; that banter is part of tradition within medicine, that we all do it to some degree, and that in some cases it even performs a ‘bonding’ function.1 This may be true, but we question the logic of protecting a tradition that stigmatises mental health, contributes to a shortfall in GPs, and ultimately puts our patients at risk.

The question is whether ‘banter’ is ever acceptable; the answer is that it depends on its form and circumstances. But one thing is clear: Badmouthing, Attitudes, and Stigmatisation in Healthcare has to stop. It will be no easy feat to change such ingrained attitudes but we can all play a part, so make a stand and #banthebash.

#banthebash is an RCPsych campaign to address Badmouthing, Attitudes, and Stigmatisation in Healthcare. The RCGP will also be campaigning against the denigration of general practice.

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